Client Information & Agreement Form
Questions? Email FlowOfLight1111@gmail.com
First Name
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Last Name
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Email Contact
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example@example.com
Phone Number
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Area Code
Phone Number
Residential Address (fill out your neighborhood region including city and state if you don't feel comfortable giving out address)
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Your Age
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Your employer, school, or where you work
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Your profession or occupation (students can enter as "Student").
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Emergency Contact (First Last Name), in case we need to contact the person on your behalf
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Emergency Contact Phone Number
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Area Code
Phone Number
Relationship with the person
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Self Assessment
Pls provide basic information about your situations and expected outcome. Your reflection and filling the information below will be helpful for your sessions.
What are the issues or situations that you wish to address during your consultation sessions?
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Pls describe how the situation started and changed over time.
What would you like to accomplish with expected outcome of such situations?
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What resources and support do you need to achieve such an outcome?
What are your inner strength and potential obstacles to achieve such outcome?
How would you like us to support you?
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Common-Sense Practices: To achieve the desired outcome and improvement, we may recommend certain self studies and home exercises. On the day of the session, we recommend you dress comfortably, drink water, eat healthily, take enough rest, avoid intense physical, emotional, and mental activities which may counteract the effects of your sessions. You are welcome to address any concerns with our office and seek alternative advice and assistance that is deemed appropriate.
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Agree
During the COVID pandemic, your consultation sessions will be most likely online through virtual meetings. However, in case your session will be held in person, public hygiene practices including wearing a mask and proper hand wash will be followed by our office and required from you too.
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Agree
Client Disclosure & Consent
Please read carefully and sign at the bottom.
Disclosure: Flow-of-Light Natural Health, hereby referred to as “the Service Provider”, does not have a registered psychologist or psychiatrist, nor a licensed therapist or counselor. The Service Provider does not diagnose or treat diseases but to support your wellbeing and life experiences. If you have any medical needs in physical or mental health issues, please seek medical care or hospitalization immediately. If you live in any harmful conditions or are under unsafe situations, please seek appropriate care right away or call 911.
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Agree
Risks and Benefits: During your sessions, you may have to disclose or discuss personal experiences and memories that may be unpleasant but are related to your current situations. Outcome from your sessions depends on the nature of the problems, your commitment, and your willingness to change. At times, you may feel worse before you feel better, or move backward before progress forward. You may gain new perspectives and attitudes that are unfamiliar to yourself and/or uncomfortable to your family and social circles. However, the choices and changes you decide to make are completely up to you and under your full control and responsibility without any obligation from your side to follow suggestions offered by this Service Provider.
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Agree
Privacy Notice: All communications between you and this Service Provider will be held in strict confidential protection unless you provide written permission to release information to others including your immediate family members and other relevant parties. For clients < 18 yrs old, the information will be available to parents or other legal guardians if both the minor and adult parties provide written consent. Exceptions to this confidentiality may include instances of suspected abuse, serious danger of harm to others or to the self, other legal requirements such as by court orders. Case materials will be also protected and kept confidentially as stated above. If such materials will be used for research and education purposes, you will be consulted for permission if you are reachable. Otherwise, personal identity will be removed for privacy protection.
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Agree
Mutual Respect: By entering this agreement, you respect and consent to the practices from this Service Provider, holding no harm or any ill intention against this Service Provider. The effect of the sessions in large depends on your openness, patience, and adherence to such intention and efforts. We are committed to helping you as long as you stay with this agreement. You are free to leave at any time and end this agreement if you or this Service Provider decides this service no longer benefits you.
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Agree
Release and Waiver of Liability: I hereby release, discharge, and covenant not to sue the Service Provider, its owners, officers, and employees from all liability, claims, demands, losses, or damages on my account caused, or alleged to be caused, in whole or in part by the Service Provider or otherwise. I further agree that if, despite this release and waiver of liability, assumption of risk, and indemnity agreement I, or anyone on my behalf, makes a claim against the Service Provider, I will indemnify, save, and hold harmless the Service Provider, its owners, officers, and employees, from any litigation expenses, attorney fees, loss, liability, damage, or cost which may be incurred as the result of such claim. I acknowledge that I have read this agreement and fully understand its terms. I am signing it freely and without any inducement or assurance of any nature, and I intend it to be a complete and unconditional release of all liability to the greatest extent allowed by law and agree that if any portion of this agreement is held to be invalid, the balance, notwithstanding, shall continue in full force and effect.
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Agree
Your legal name (First Last)
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If < 18 yrs, parent or legal guardian's name (First Last)
Date (Day, Month, Year)
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Your signature
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If < 18 yrs, parent or legal guardian's signature
Thank you for your patience. Congratulations on getting your journey started!
Please email our office if you have any questions on this form: FlowofLight1111@gmail.com
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